Alongside “Why does the Senator from Montana get to dictate this thing?” Ezra’s is a perennial question of health reform. Every time, public debate begins with heart-rending stories of uninsured or underinsured peoples’ difficulties: the poor person receiving sub-standard care, the man losing his home because he got cancer or was hit by a car, the Alzheimer’s patient who loses her lifesavings to nursing home bills. Then at some point in the process, the human face of the problem is lost, its urgency obscured by mind-numbing debates over insurance exchanges, CBO cost estimates, and multiple flavors of co-ops and public plans.

Liberals contribute to the fog, because of a genuinely difficult strategic calculation we confront. Trying to promote humane policies within a society that displays such tenuous commitment to our disadvantaged fellow citizens, we fear that straightforward appeals to helping the uninsured or helping poor people will fall flat with the political majority. So we are forced to fall back on technocratic arguments about improving quality and cost-effectiveness to reach those of us who are already well-insured. The technocratic arguments are legitimate, but they leave aside much of the story. “If you like what you have…” readily becomes the dominating predicate. “Does it pay for itself?” becomes more urgent than: “Who is left out?”

The same dilemma arises in other domains, too. People like me favor needle exchange because we want to protect people from an agonizing death due to HIV/AIDS. Adam Doster notes that we favor less punitive criminal justice policies because we mourn the incredible loss of human potential caused by lengthy incarceration of hundreds of thousands of people.

Yet we fear that if we make these arguments straight-up, we will lose. We fear that too few Americans feel the same way about injection drug users and criminal offenders. So we present drawers full of cost-benefit analyses showing that needle exchange reduces public expenditures, and that much of the benefit goes to non-drug-users. We argue that locking so many nonviolent drug offenders in 8-by-10 cages diverts scarce public resources from more efficient investments.

These cost-benefit analyses are actually correct. Ironically, though, they are viewed with suspicion by citizens and policymakers, who regard these as thinly-disguised political briefs from liberal advocates who would favor progressive policies even if the particular cost-benefit analysis had worked out the other way.

In conceding ground to a dry policy discourse that downplays the moral urgency of collective obligation, we unilaterally surrender some of the best moral and political arguments for health reform. It’s a genuine dilemma. We must legislate in the society we actually have, not in the society as we wish it to be. So we present a rather cold-hearted calculus to sell humane policies. This isn't a stupid calculation, but I’m starting to think it is the wrong approach.